58N-1.001: Application Process
58N-1.003: Service Descriptions
58N-1.005: Service Provider Qualifications
58N-1.007: Program Standards and Operating Procedures
58N-1.009: Care and Service Standards
58N-1.011: Outcome Measures
58N-1.013: Quality Assurance Standards
58N-1.015: Utilization Review
58N-1.017: Grievance and Conflict Resolution Procedures
58N-1.019: Service Satisfaction
PURPOSE AND EFFECT: The proposed rules comply with Section 430.706, F.S., which requires the department, in consultation with the Agency for Health Care Administration, to “develop quality of care standards for community diversion pilot projects.” At a minimum, these “standards must include, but are not limited to, outcome measures, utilization review, grievance and conflict resolution, patient satisfaction, and care and service standards.”
SUMMARY: The proposed rules include the long-term care community diversion pilot project provider application process, including three application forms incorporated by reference; service descriptions and service provider qualifications; program requirements; care and service standards, including a uniform disenrollment form incorporated by reference; outcome measures; quality assurance standards, utilization review; grievance and conflict resolution; and service satisfaction.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 430.706 FS.
LAW IMPLEMENTED: 409.912(27), 430.705(2)(b)2., 430.706, 641.3155, 641.51, 641.511 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: September 18, 2007, 1:00 p.m. – 5:00 p.m. EST.
PLACE: Department of Elder Affairs, 4040 Esplanade Way, Conference 225F, Tallahassee, FL 32399-7000
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 72 hours before the workshop/meeting by contacting: Jim Crochet, Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, FL 32399-7000; telephone number (850)414-2000, SunCom 994-2000; Email address: crochethj@elderaffairs.org. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Jim Crochet, Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, FL 32399-7000; telephone number (850)414-2000, SunCom 994-2000; Email address: crochethj@elderaffairs.org
THE PROPOSED RULE AND FORMS INCORPORATED BY REFERENCE IN THE RULE MAY BE OBTAINED ON THE DEPARTMENT INTERNET AT http://elderaffairs.state.fl.us UNDER THE HEADING ENTITLED “DOEA RULEMAKING.”
THE FULL TEXT OF THE PROPOSED RULE IS:
58N-1.001 Application Process.
(1) Applicants who wish to apply as a provider for the Long-Term Care Community Diversion Pilot Project must complete DOEA Form LTCD-001, Department of Elder Affairs Long-Term Care Community Diversion Pilot Project Provider Application, July 2007, which is hereby incorporated by reference.
(a) The form is available from the Department of Elder Affairs (DOEA) Web site at http://elderaffairs.state.fl.us/english/forms/DOEAformLTCD001.pdf. The form is also available for the following address: Department of Elder Affairs, Division of Statewide Community-Based Services, Long-Term Care and Support,
(b) Applicants must follow the instructions in completing the application and submit it to the address as instructed on the application cover sheet.
(2) In addition, applicants must also enroll as Medicaid providers by completing the following Agency for Health Care Administration (AHCA) forms:
(a) AHCA form 2200-0003 (December 2004),
(b) Non-Institutional Medicaid Provider Agreement (February 2007).
(c) These forms are hereby incorporated by reference and may be obtained from the AHCA Web site at http://floridamedicaid.acs-inc.com/XJContent/Non-Institution al%20Provider%20Agreement?id=000003568505 and http://floridamedicaid.acs-inc.com/XJContent/Florida%20Medicaid%20Provider%20Enrollment%20Application?id=0000007453 63, respectively.
(d) These forms must be submitted to the department along with DOEA Form LTCD-001.
Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.
58N-1.003 Service Descriptions.
A long-term care community diversion pilot project provider (hereafter referred to as “diversion provider” or “provider”) must either provide or arrange for services in accordance with the requirements in its contract with the department and the requirements in the Florida Nursing Home Diversion Waiver under the Agency for Health Care Administration’s (AHCA) Medicaid program.
Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.
58N-1.005 Service Provider Qualifications.
The qualifications for individuals or entities providing services as outlined in Rule 58N-1.003, F.A.C., must be in accordance with the requirements of the diversion provider’s contract with the department, the requirements of the AHCA
Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.
58N-1.007 Program Requirements.
Diversion providers must meet the requirements addressed in Section 430.705(2)(b), F.S., and in its contract with the department.
Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.
58N-1.009 Care and Service Standards.
(1) Medicaid Waiver Services: With the exception of nursing facility services, the long-term care services included under the diversion pilot projects are authorized under the
(2) Case Management. Case management services must be provided by case managers directly employed by the diversion provider.
(a) Case managers must meet at least one of the following qualifications:
1. Have a Bachelor’s Degree from an accredited college or university in social work, sociology, psychology, gerontology or human services related field; or
2. Have a Bachelor’s Degree from a college or university and have at least two (2) years of related case management experience; or
3. Be a registered nurse licensed to practice in the state; or
4. Be a licensed practical nurse licensed to practice in the state with three (3) years of geriatric or related experience.
(b) In addition to any other training required, the diversion provider must ensure that case managers annually attend and complete the following training:
1. Abuse, neglect, and exploitation training specifically involving the elderly;
2. Four (4) hours of in-service training on issues affecting the frail elderly; and
3. Alzheimer’s disease and related disorders annual continuing education training from a qualified individual or entity, focusing on newly developed topics in the field.
(c) The diversion provider may employ paraprofessionals, such as case aides, to assist case managers.
1. Case aide services are adjunctive to case management services and may be provided by paraprofessionals under the direction of case managers.
2. Case aide services include assistance with:
a. Implementing plans of care by arranging and verifying the services provided by the subcontractors;
b. Obtaining access to appointments and other services as prescribed in the plans of care; and
c. Arranging linkages between providers and participants.
3. Case aide services do not include:
a. Developing plans of care;
b. Conducting assessments or reassessments; or
c. Participating directly with assessing participant health status, medical follow-up or discharge planning.
(d) At a minimum, case managers must have one face-to-face visit with each participant at least every ninety (90) days from the date of enrollment.
(e) The case manager must make the necessary emergency plans or other shelter arrangements with the participant or representative during the enrollment orientation process.
1. The emergency plan must include arrangements for emergency supplies, transportation to the emergency location, and assistance in the coordination of emergency services with the participant’s family or other shelter arrangements.
2. The participant must be provided with the diversion provider’s emergency contact number.
3. The case manager must review and update the participant’s emergency/disaster plan with the participant or representative at least annually.
(3) Care Planning:
(a) Each participant must have a care plan. The care plan is the tool used by the case manager to document a participant’s assessed needs, desired outcomes, and services to be provided. The care plan is a plan of action, developed in conjunction with the participant, caregiver and/or family member or representative, and to the extent possible, the participant’s physician. It is designed to assist the case manager in the overall management of the participant’s care.
1. At each face to face visit, the participant or representative and case manager must review the care plan and make changes, if necessary, to meet the participant’s continuing needs. The participant or representative and case manager must acknowledge in writing that the care plan was reviewed and changes to the care plan were agreed upon, if applicable.
2. At any time a significant change is indicated, the participant or representative and case manager must acknowledge the change in writing.
3. The participant or representative must receive a signed and dated copy of the care plan or care plan summary.
(b) All changes in services in the care plan must be documented in the participant’s file.
(4) Emergency/Disaster Plan and Plan for Continuity of Operations.
(a) The diversion provider must submit an emergency/disaster plan to the department no later than April 30th of each year. The plan must include a list of names and contact information for members of the provider’s disaster and emergency management team.
(b) The diversion provider must submit annually a continuity of operations plan (COOP). The plan must include:
1. Risk assessment of the physical and operational environment, the information technology that supports that environment and an analysis of the potential impact a disaster, emergency or other significant business interruption would have on critical functions in service delivery.
2. Procedure for the maintenance of communications, security controls and continued protection of confidential data and information contained in both electronic and hard copy formats, including alternate sites for facility operations, data operations and related functions.
3. Notification protocol for initiation of the plan and for continued communications between essential staff, stakeholders, the department and participants, including a regularly updated list of names and functions of essential emergency team members.
4. A recovery strategy to include restoration of normal operations and systems and notification protocol for staff, participants, other stakeholders and the department throughout the recovery process.
5. Annual schedule for training in emergency procedures for essential team members and staff, and inspection and testing of facilities and equipment both on-site and alternate or back-up facilities or equipment.
(5) Disenrollments:
(a) In order to disenroll a participant from the diversion program, the diversion provider must complete DOEA Form LTCD-002, Department of Elder Affairs Long-Term Care Community Diversion Pilot Project Request for Disenrollment, July 2007, which is hereby incorporated by reference and available at the department’s Web site at http://elderaffairs.state.fl.us/english/forms/DOEAformLTCD002.pdf or from the following address: Department of Elder Affairs, Division of Statewide Community-Based Services, Long-Term Care and Support Unit, 4040 Esplanade Way, Tallahassee, Florida 32399-7000, Telephone number (850)414-2000.
(b) Upon notification of a participant’s death, the diversion provider must disenroll the participant and void any claims for the months following the participant’s death. The diversion provider must notify the local offices of the Comprehensive Assessment and Review for Long-Term Care Services (CARES) and Department of Children and Families.
(c) The diversion provider must submit a copy of voluntary disenrollments to the local CARES office. In addition, the provider must submit all disenrollment transactions to the Medicaid fiscal agent via electronic submission or other method as set forth in its contract with the department.
(d) The CARES office must not accept disenrollment forms from anyone other than the participant’s current diversion provider.
(e) The current diversion provider must continue to provide services to the participant until the documented effective date of disenrollment.
Specific Authority 430.706 FS. Law Implemented 430.705(2)(b)2., 430.706 FS. History–New__________.
58N-1.011 Outcome Measures.
(1) Service Provider Reimbursement: Diversion providers must demonstrate that service provider reimbursements meet the timeliness requirements according to Section 641.3155, F.S.
(2) Diversion Provider Reporting: Diversion providers must demonstrate that required reports outlined in their contracts with the department are submitted to the department on or before the due date.
Specific Authority 430.706 FS. Law Implemented 430.705(2)(b)3., 430.706, 641.3155 FS. History–New__________.
58N-1.013 Quality Assurance Standards.
The diversion provider must develop a quality assurance program with written policies and procedures. The quality assurance program must comply with applicable provisions of Sections 409.912(27) and 641.51, F.S., and the diversion provider’s contract with the department
Specific Authority 430.706 FS. Law Implemented 409.912(27), 430.706, 641.51 FS. History–New__________.
58N-1.015 Utilization Review.
As part of its quality assurance program referenced in Rule 58N-1.013, F.A.C., each diversion provider must develop a utilization review methodology that must include, at a minimum, the following elements:
(1) Participants who received services with adverse or unexpected outcomes;
(2) Management of participants’ care;
(3) Appropriateness and timeliness of services provided;
(4) Comprehensiveness of the care plan and the participant’s compliance or non-compliance with the care plan, and the effects on the desired outcomes;
(5) Evidence of special screening for, and monitoring of, high-risk participants whose diagnoses may result in adverse outcomes; and
(6) Evidence of resolution of service satisfaction issues.
Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.
58N-1.017 Grievance and Conflict Resolution.
Diversion providers must have detailed written procedures in place for participant grievance and appeal processes in accordance with applicable state and federal laws for the particular type of diversion provider.
Specific Authority 430.706 FS. Law Implemented 430.706, 641.511 FS. History–New__________.
58N-1.019 Service Satisfaction.
(1) Diversion providers must conduct participant and caregiver (family/representative) service satisfaction surveys and report the survey results in accordance with the requirements outlined in its contract with the department.
(2) Diversion providers must submit statements of validity, reliability and unbiasedness along with the results of the participant and caregiver satisfaction surveys.
(a) The validity and reliability statements must address how participants and caregivers for these surveys have been statistically or otherwise established.
(b) The unbiasedness statement must address the measures that the provider utilized to ensure the independence of the survey and the trust of the respondent.
(c) The statements must be signed by the authorized representative of the diversion provider.
(3) The diversion provider must retain copies of satisfaction survey results for review during the department’s monitoring process to determine its compliance with the requirements of its contract with the department and subsection 58N-1.015(6), F.A.C.
Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.